As More Parents Refuse Vaccines, More Doctors Dismiss Them -- With AAP's Blessing

The tides are shifting for parents who delay or refuse vaccines and the doctors who treat them: More pediatricians are seeing more vaccine refusals, and more pediatricians are pushing back. But now, those doctors pushing back have a bit more support from the American Academy of Pediatrics.

Several new reports in the journal Pediatrics today confront the changing landscape of vaccine hesitancy in the U.S. head on. The professional organization firmly declared its support for removing all non-medical exemptions for vaccines, released findings from pediatrician surveys on immunization and issued comprehensive guidance to pediatricians for addressing parents’ concerns about vaccines. And it shifted somewhat on the issue of doctors firing patients for refusing to vaccinate.

But doctors’ dismissal of non-vaccinating families has remained controversial because the AAP has not promoted or supported dismissing families who don’t vaccinate for non-medical reasons. The organization instead urges pediatricians to continue providing unvaccinated children with healthcare while still attempting to persuade the parents to vaccinate.

But the AAP’s new technical report on confronting vaccine hesitancy offers more leeway for pediatricians who dismiss vaccine refusers: an acknowledgement that it’s acceptable after doctors have tried everything else.

“The decision to dismiss a family who continues to refuse immunization is not one that should be made lightly, nor should it be made without considering and respecting the reasons for the parents’ point of view,” the report states. “Nevertheless, the individual pediatrician may consider dismissal of families who refuse vaccination as an acceptable option.”

Pediatricians Express Mixed Responses

This softened stance has been a long time coming for the many pediatricians who already have dismissal policies but did not feel comfortable appearing to be out of step with the AAP.

“I’m glad the Academy has finally decided to support the pediatricians who are not accepting non-vaccinated patients,” said Alla Gordina, MD, FAAP, a pediatrician at Global Pediatrics and Family Medicine in East Brunswick, New Jersey. Her practice will not accept patients who are not up to date on immunizations and are choosing not to vaccinate. “I have two patients in my practice who cannot be vaccinated for medical reasons,” she explained. “I have to protect them. I have to protect babies who cannot be vaccinated because of their age.”

Phil Boucher, MD, FAAP, is a pediatrician in private practice in Lincoln, Nebraska, who feels similarly. He will work with vaccine-hesitant parents for many months, nearly all of whom eventually come around, and he will accept parents who refuse vaccines only during the early newborn period to be sure the infant is safe. If progress on vaccinations hasn’t been made by 4 to 6 months, it’s time for that family to move on.

“I consider immunizations to be a foundation of pediatric practice. If parents disagree with me over that, I find we end up disagreeing over a number of important pediatric principles,” Boucher said. “The pediatrician-parent-patient relationship is built on trust. If parents don’t trust my medical opinion, it is difficult to maintain that relationship.”

But it’s that very relationship that leads Dan Flanders, MD, FAAP, director of Kindercare Pediatrics in Toronto, not to have a vaccinated-families-only policy.

“I can see how a ‘threat to dismiss’ may coerce some families into conceding and agreeing to vaccinate,” Flanders said. “What I fail to see, however, is how this helps, from a broader perspective, to build trusting and family-centered relationships between doctors and patients. How can one build a successfully therapeutic relationship based on coercion and fear?”

He also believes the “mandate to protect the health and well-being” of patients precludes dismissing families. “I worry that when pediatricians dismiss vaccine-hesitant families, it is the children who suffer for their parents’ poor, uninformed choices.”

Nathan Boonstra, MD, FAAP, a general pediatrician at Blank Children's Pediatric Clinic in Des Moines, Iowa, also sees more nuance in the issue of vaccine-refusing patients in his practice.

“Vaccine refusal is complex, and every parent who refuses has a unique path that brought them there,” Boonstra said. “It doesn't necessarily mean they reject evidence-based recommendations across the board, or don't trust their doctor.”

He also points out that the risk an unimmunized child in the waiting room poses to other children is small, especially given other non-vaccine-preventable illnesses circulating.

“There may be more of a risk in some communities where immunization rates are very low, and there may be more of a need for such a policy in those situations,” he said. “But in most clinics, there are ways to reduce that risk further, such as trying to keep immunocompromised children out of waiting rooms as much as possible.”

Daniela Chavarriaga holds her daughter, Emma Chavarriaga, as pediatrician Jose Rosa-Olivares, M.D. administers a measles vaccination during a visit to the Miami Children's Hospital on June 02, 2014 in Miami, Florida. (Photo by Joe Raedle/Getty Images)

“I don’t think I could go to a pediatrician who wasn’t strict at this point,” she said. Although she sees the benefit in not having more parents seek out “delay/refusal-friendly” doctors, “I’m a bit on edge after my own experience,” she adds.

In general, parents’ attitudes toward pediatrician policies that dismiss non-vaccinating families are as diverse as vaccine-hesitant parents themselves are. I solicited opinions from those on my Facebook feed about such practices and, while those responses certainly do not represent the country at large, even my select group of acquaintances had widely varying opinions.

Jessy Hull of Fayetteville, North Carolina, prefer a strict policy of “no vaccine, no admittance.” “I don’t want my child exposed to a preventable illness that he is too young to be vaccinated against because someone doesn’t want to vaccinate,” she said.

Heather Childers, of Denton, Texas, prefers her son have a pediatrician who only accepts vaccinating patients because she doesn’t choose “to be willfully negligent and not vaccinate him.” But if a practice does cater to families who refuse vaccinations, she believes a notice at the check-in desk should make that clear.

“I would struggle to have faith in a doctor who allows non-vaccinated kids around sick kids and infants who are too young to be immunized,” said Elizabeth Souder-Philyaw, of Dallas, Texas.

But other parents feel differently, such as Alexis Weinstein in Hillsdale, New Jersey. “If all pediatricians start turning away parents who don’t vaccinate, it just pushes them farther into an anti-vax echo chamber,” she said. She sees the risk of her children catching a disease as just as likely at the mall or dance class as at the doctor’s office, so she would prefer non-vaccinating parents continue seeing their pediatrician and receiving information on vaccines in case they eventually change their minds.

“My children's pediatrician does accept patients who are unvaccinated, and I don't push them to change,” said Karen Ernst, director of the parent advocacy group Voices for Vaccines. “My children are fully vaccinated, as is encouraged by our pediatrician, and I understand that the real risk to my children is very low, and possibly lower because unvaccinated children are not clustered or ostracized to one practice. However, I know for some children, there is no choice. If my children were undergoing chemotherapy or needed an organ transplant, I might make a different choice.”

Parent Effie Greenhouse of Portland, Oregon, an area of the country known for lower vaccination rates, feels similarly. She said she has never felt uncomfortable taking her children on playdates with the children of a friend who delays vaccines, and she understands her children might be in the waiting room with children not yet fully caught up on vaccines.

“But I get worried that if my doctor and most other doctors shun parents who are refusing or delaying vaccinations, and all of those families then cluster at a few remaining doctors' offices, our chances of an outbreak could increase,” Greathouse said. “If a practice has a lot of non-vaccinating families, it seems like an outbreak could really take off and spread further, so I want my doctor to see vaccine-hesitant and vaccine-refusing families. I want those kids to get the benefits of herd immunity, too.”

Fellow Oregonian Alice Callahan, of Eugene, doesn’t know of any practices that have a vaccinate-or-leave policy, probably because the area has high vaccine exemption rates. “It would be my preference to have a pediatrician who only took vaccinating families, but from a public health standpoint, I’m not sure it’s the right thing to do.”

And that’s the question: As the report points out, no data exist on child outcomes in areas where vaccine-refusing families are dismissed.

“Do they largely immunize? How many seek alternative medical care from substandard, non-evidence-based practitioners, or receive no care at all? Do they cluster in a small number of clinics, possibly undermining herd immunity and increasing the risk of outbreaks?” Boonstra asked. “If there's a case to be made for dismissing families who don't immunize, it lies in this information. We have a lot of anecdotes about what physicians think the outcomes are, but no evidence, and even then we still have to consider the needs of those children who are dismissed from practices.”

Surveys Suggest Increase in Refusals and Dismissals

Accompanying the new report on vaccine hesitancy is a study that compared pediatricians’ responses to surveys on immunization in 2006 and 2013. Responses from 629 pediatricians in 2006 and 627 pediatricians in 2013 revealed several shifting trends over the past decade:

Pediatricians reporting that at least one family refused at least one vaccine increased from 75% in 2006 to 87% in 2013.

They estimated that 8.6% of parents in their practice refused at least one vaccine in 2013, compared to 4.5% in 2006.

Parents refusing all vaccines rose from 2.1% to 3.3%.

Nearly one in five parents (19%) requested delaying at least one vaccine for a non-medical reason.

The reasons parents want to delay vaccines are predictable: 75% are concerned about their child’s discomfort, and 73% worry about vaccines overwhelming a child’s immune system (which has been shown not to happen). But delaying wasn’t much of a thing until Bob Sears introduced an “alternative vaccination schedule” which has never been tested for safety or effectiveness. “There has been greater recognition among pediatricians that delayed or incomplete vaccination schedules are probably responsible, at least in part, for the spread of measles in [the Disneyland] outbreak,” the AAP report stated.

But more surprising was the top reason parents wanted to skip vaccines altogether: 73% of vaccine-refusing parents saw vaccines as “unnecessary.” When parents don’t see the diseases around them, they don’t see a need to protect their children from them.

But there’s good news in the survey: One third of parents changed their mind and agreed to their child receiving a vaccine they had initially refused after the doctor provided vaccine education. It took an average 16 weeks before parents gave permission for the vaccine after first turning it down. (Nine percent of pediatricians said education their patients about vaccines did not change any parents’ minds, but the surveys didn’t ask doctors’ specific approaches in educating parents on vaccines.) Further, concerns about autism or thimerosal have dropped 10 percentage points, from 74% to 64%, and slightly fewer vaccine-refusing parents remain as concerned about side effects from vaccines.

It’s important to note, however, that these survey results came before the Disneyland measles outbreak in 2015 and multiple other pertussis and measles outbreaks. These outbreaks have “convinced all but the steadfastly delusional that this is a real and dangerous problem,” said Herschel Lessin, MD, a senior partner at The Children’s Medical Group, PLLC in Poughkeepsie, New York. It has also helped, he adds, that “the media have finally stopped being co-dependent with this fringe group in reporting the truth about vaccines and debunking the lies and fabrications of the anti-vaccine fringe groups.”

Still, these findings simultaneously suggest progress is being made even while more is to be done—and by more than just physicians, according to Ernst of Voices for Vaccines.

“Communities benefit from high immunization rates, and as such, easing vaccine hesitancy is not just the job of a pediatrician, but of the entire community,” Ernst said. “School administrators, vaccinating parents, public health agencies, lawmakers and pediatricians need to elevate immunization as an important and shared community value. When it becomes a community value, pediatricians might not find themselves in a bind about keeping or dismissing vaccine-refusing patients.”